a mistake…

Posted on Monday 28 May 2012

I’ve been moderately obsessed with a single topic of late. It’s something that happened to psychiatry back around 1980-ish with the coming of the DSM-III. My obsession is personal, because it happened to me. We all know that both Managed Care and the Pharmaceutical Industry were major forces in how things have played out, but that’s not what obsesses me. I’m sure that I am over-playing it a bit, but my thoughts about it remain focused on the diagnosis – Major Depressive Disorder. From the days back when it was happening and throughout my career, I’ve thought it was in error, a mistake. At times, I thought it was something evil, something somebody created just to build a market for medications. But I’ve come to believe what I’ve been told, that the Pharmaceutical and Third Party payers may have jumped on the Diagnosis like it was heaven sent, but they didn’t create it. I was doing what paranoid people do, assuming a malevolent motive based on a negative phenomenon. I now think it was just an error, a mistake that started a brush fire the industries then exploited and perpetuated – aided and abetted by some among us who became the devil’s own helpers. Back in those days, I wasn’t close enough to the forest to know what ignited it. By the time I was aware of it, it was a raging inferno. So I’m obsessed with reconstructing the kindling point.

When I wrote what price reliability…, I was trying to figure out how in the world the category Major Depressive Disorder ever came into being in the first place, and I wasn’t having much luck. It just seemed to appear. By 1978 [Research Diagnostic Criteria: Rationale and Reliability], it was a diagnosis and all the former kinds of depression were listed as under it as subtypes in Robert Spitzer’s Research Diagnostic Criteria [RDC]. By then, he had concluded that there weren’t clear borders for the subtypes. I started trying to look at why they were ever subtypes in the first place.

Later, in hypothesizing…, I chased it back to 1975, and was playing with what I facetiously called the 1boringoldman-inertia-of-serendipity-hypothesis. That was the very unsatisfying idea that the unitary class, Major Depressive Disorder, wasn’t really ever a thought-about thing. It just sort of happened. That it started life as a placeholder for a bunch of former diagnoses, but because they couldn’t be easily separated, it endured and ended up passively being declared a Disorder. What makes that so unsatisfying and actually tragic is that as Major Depressive Disorder, something I consider a non-discrete entity, it became a vehicle for an epidemic of clinical trials that ended up with FDA Approvals. Playing like Major Depressive Disorder was a genuine bonafide Disease with a genuine bonafide treatment gave Pharma a market for their SSRI blockbusters, and ultimately gave psychiatry black eyes for massively over-diagnosing and over-medicating. It sure wasn’t right for our patients. Here’s how it had been before:


      000-796 Involutional psychotic reaction
      000-xll—000-xl3 Manic depressive reactions
            000-xll Manic depressive reaction, manic type
            000-xl2 Manic depressive reaction, depressed type
            000-xl3 Manic depressive reaction, other
      000-xl4 Psychotic depressive reaction
      000-x06 Depressive reaction


      296 Major affective disorders…
            296.0 Involutional melancholia
            Manic-depressive illnesses…
            296.1 Manic-depressive illness, manic type…
            296.2 Manic-depressive illness, depressed type…
            296.3 Manic-depressive illness, circular type…
                  296.33 Manic-depressive illness, circular type, manic
                  296.34 Manic-depressive illness, circular type, depressed
            296.8 Other major affective disorder…
      298.0 Psychotic depressive reaction…
      300 Neuroses
            300.4 Depressive neurosis

There was something comforting about those systems. The task was clear. With a depressed person, the diagnostic dilemma was categorical. It was like my medical mind? [Severe shortness of breath. Heart Disease? Lung Disease?][Severe Depression.  Major Affective Disorder? Depressive Neurosis?]. It directed what came next. Neither category was quite right: in the first group, what about a person with Melancholia with no previous episodes? in the second, neither Depressive reaction nor Depressive neurosis quite fit the bill, as there are a sea of ways that life, the mind, and the personality can weave together in a given depression – certainly not all covered by the definitions or mechanisms in the DSM code books. But still, there was a categorical separation that helped me think about the case in front of me. I never had that from the DSM-III, so I never paid a lot of attention to it. Major Depressive Disorder didn’t move me anywhere in my understanding of a case.

But that’s not what Robert Spitzer had that in mind.  He had a couple of things to work with. He had resident John Feighner’s simple and naive classification with its adherence to descriptive criteria, and he needed to get rid of the categories defined by psychoanalytic mental mechanisms like Depressive Neurosis. When it came to Depression, he had to deal with the kinds of depressive illness. When John Feighner did his classification [1972], he simply classified discrete illnesses, episodes, and didn’t even bother with diseases like Manic-Depressive Illness [though that was a big topic in St. Louis]:


And when Dr. Spitzer et al built their Research Diagnostic Criteria classes around 1974, they followed both Feighner and the DSM-II:
There were the discrete illnesses after Feighner:
    Manic Disorder
    Major Depressive Disorder
But they added a "lite" version for each:
    Hypomanic Disorder
    Minor Depressive Disorder
And each one of those four had a recurrent form:
    Bipolar with mania [bipolar I]
    Bipolar with hypomania [bipolar II]
    Recurrent Unipolar
    Intermittant depressive disorder 
The only inconsistency in the mix was that Recurrent Unipolar was not a diagnosis on its own [not a Disorder], but rather a subclass of Major Depressive Disorder, along with all the other ways depression had been parsed previously, listed as non-mutually exclusive categories:

    Recurrent Unipolar
    Predominant Mood

Here are the category definitions for the Research Diagnostic Criteria [RDC] from early on in its history [1975]:

There is no agreement within our field as to the generic name for an episode of serious depressive illness. We use the term "major depressive disorder" as it seems general enough to encompass the many further subdivisions that are the basis of much current research. This category includes some cases that would be categorized as neurotic depression, and virtually all that would be classified as involutional depression, psychotic depression, and manic depressive illness, depressed type. The criteria for major depressive disorder are very similar to the Feighner criteria for depressive illness…

There is even more controversy as to the best way of classifying subjects who are bothered from time to time more than most people by depressive mood and associated symptoms but who do not meet the full criteria for major depressive disorder. The RDC set categorizes such patients in four different ways.

  • Minor Depressive Disorder This category is for nonpsychotic episodes of illness in which the most prominent disturbance is a relatively sustained mood of depression without the full depressive syndrome, although some associated features must be present. It may be chronic or episodic.
  • Intermittent Depressive Disorder
  • Cyclothymic Personality
  • Labile Personality
In my next post, I’ll explain why I’m so stuck on this topic, and why I think that a crucial error was made the day that RDC outline was first written – an error that persists almost 40 years later. But for the moment, I’ll just say that the separation between Major Depressive Disorder and Minor Depressive Disorder was quantitative, neither qualitative nor categorical. So even before we get to the part about about how they handled the subcategories of Major Depressive Disorder in the RDC, I’ll end this post simply. They were wrong. This diagnostic schema implied something like a continuum. That wasn’t true in the earlier versions of the criteria [DSM & DSM-II]; it wasn’t true in 1974; and it’s still not true. The differences in the depressions is qualitative, not quantitative. I no longer think this was an intentional error. It was rather a mistake, but it haunts us…
    May 29, 2012 | 1:16 AM

    an interesting article on Spitzer, if you haven’t seen it,tells of the making of DSM3

    Bernard Carroll
    May 29, 2012 | 1:33 AM

    Yes, it was a historic mistake. The consequence has been 30+ years of crippled research in depression. I was involved in the debate back then – in fact, in the APA archives there is a letter I sent to Robert Spitzer in 1979 imploring him to reconsider, making exactly the same arguments you make in this post. What is astounding is that the DSM-5 people are proceeding to leave the fundamental error in place.

    May 29, 2012 | 2:05 AM
    May 29, 2012 | 7:47 AM

    I can see where the the variations fit, but I wish you guys/the powers that be, would spend more time trying to FIX our troubled depressed brains that are constantly frustrating us & preventing us from living full lives. The temptation to cut life short rather than live it like this is massive.

    Nick Stuart
    May 29, 2012 | 1:02 PM

    Before something can be fixed, one must first be sure of what that ‘thing’ actually is. The idea that your ‘troubled depressed brain’ is somehow separate or different from who you are and how you think is just a myth of biological psychiatry which the DSM promotes but which to my mind is misguided at best. Unfortunately there are no magic cures or pills to be found here.

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